Notes from the Dual Eligible Planning Grant Long Term Services and Supports Work Group Agenda September 19, 2011

The group introduced themselves and discussed what they brought to the workgroup.

The group asked about the 646 Demonstration and wanted a brief overview. Angela Floyd explained the 646 Demonstration as a 5 year demonstration with 8 networks representing 26 counties. The demonstration aims to assist in managing the dually eligible patients when Medicare data is made available for the networks. Currently, networks and Community Care have a robust Informatics Data warehouse of Medicaid paid claims data, but lack complete Medicare claims data. This demonstration provides Medicare data for the patients in the 8 networks that are seen by a provider who has agreed to be a 646 provider. In Year 1, the demonstration will focus on improving care in 18 Performance Measures increasing the number of performance measures each year. If successful, Community Care will also manage the Medicare-only population in Year 3.

Elise mentioned that the 646 demonstration is different from the effort in that 646 is a Demonstration Project and is not statewide. This planning grant (Dual Eligible Planning Grant) will focus on statewide implementation. Angela will share the 646 Overview and performance measures with the group.

Others mentioned that there are several initiatives underway in networks related to managing the dual population and that it will be difficult to determine which effort takes credit for any potential cost savings and improvement in outcomes. The Transitions Workgroup will be addressing this issue.

We will want to be clear in our proposal to CMS regarding what are long term care services and supports. Forty percent of duals have at least 1 ED visit per year. Existing initiatives discussed:  PACE( Program for All Inclusive Care for the Elderly);  Adult Day Health Programs and  LTC Acute Beds.

Who will tell the patient about how to access services when they have both Medicare and Medicaid, two different toll free numbers to call for questions?

Integrating evidence- best practice initiatives across residential and community settings, in partnership with the networks are:

 Self management  Fall prevention  We have until December to come up with our plan  Enrollment will be a challenge

1 | P a g e Explore flexibility in regular Medicaid and Medicare system covered services. The group cited examples:

 Portable x-rays were once available in the nursing homes – now everyone sent to the ED when they fall due to changes in Medicare coverage.  Mobile crisis teams come in to assess patients instead of auto referral to the ED.  Initially CAP/DA did not have services definitions and more flexibility existed, such as buying AC units for patients  Services for caregivers such as respite care, allowing them to be transported with the patient to medical appointments  Impact of transitions from one care setting to another – home to nursing home  Medicare not paying for Personal Assistant Hours  Many people could use chore worker services to help with daily activities such as cutting grass  Currently the person can only receive services in the home  Rural areas have limited workforce and the amount to pay for these services?

Refer to a wide range of assistance, medical and health services, needed to support an individual who is living with a disability or chronic illness.

 CAP/DA has a 16 month waiting list  Discussed a pilot in Wilkes county where Nurse Practitioners worked 40 hours per week with LPNs and RNs in nursing homes to prevent ED and readmits. The pilot results in some patients being discharged to a lower level of care. The Nursing Home Association was not allowed to bill separately for the NP services. Evercare providers are allowed to bill both Medicare and Medicaid. The results of the pilot showed savings. The challenges with nursing home patients’ care is on the Medical Home workgroup charge.  Palliative Care should be made available in the nursing homes and work to educate nursing homes on the differences between palliative care consults and Hospice. Some patients receiving skilled care are also getting Hospice and this is a waste of money. Nurse Practitioners take the time to discuss Palliative Care.  Patients with dementia have a different trajectory than patients with other diseases; they are significantly functionally impaired years before death compared to patients without dementia who have functional decline months before death. 50 to 70% of patients in nursing homes have underlying dementia and change the patterns of health care. We need to be aware of this in our plan.  Appropriate interventions at Senior Centers, Adult Day Care and Senior housing – health promotions such as BP checks and diabetes checks.  Waivered services not available under traditional Medicaid covered services.

Hospital to Home Grant through the Duke Endowment is a model working on how to Transition patients and provide the following services:

 Meals  Medicaid assistance 2 | P a g e  Transportation  Extra home care hours

Discussed the need for home safety alert and keeping the equipment up to date. Only covered for waivers. DMA equipment gets outdated

For the medical home, assure that we have access to clinicians to determine needs: Speech Therapy for adults must be provided in the medical home.

Transitions to home that are not covered by Medicare such as renovations to homes – covered by Medicaid for waiver patients

Challenges include:

 CARELINE was eliminated  Long Waits for home delivered meals  Jim Graham discussed a large number of patients not getting meals on wheels and the possibility of delivering meals and providing care management support for some basic health education.  Tele-health grants for Congestive Heart Failure and Hypertension have been operational in several networks. Telehealth is a covered service for tele-psychiatry. Home Health agencies can bill for visits to tele-health patients, but the networks are not reimbursed separately if they visit tele-health patients. The pilot has proven successful.  Section 8 Housing for duals – Can the code for housing follow a universal design so that all Section 8 homes are suitable for the duals. Some networks are working with their local housing authorities.  Caregivers are paid for providing services for their family members in some specific situations. DMA may need to further define. The CAP/MR program is reducing the hours.  Elise mentioned two documents available for review on the web: Cash and Counseling for consumer Directed Care and Hospital at Home in Maryland.  Discussions are the Hospice stigma and having physicians state that patient has 6 month or less to live. The group thought the 6 month requirement had been relaxed. Needs further research

We have not been instructed as to how CMS will evaluate the proposals. They have indicated that it needs to be a broad and involved process and the policy must be replicable across states. North Carolina has the infrastructure of the medical home and is well positioned.

What others need to be included in the work group:

 Primary Care Providers  Adult Day Services providers  DSS representation 3 | P a g e  Beneficiaries  DME expert from DMA  Waiver expert from DMA  Care managers  Discharge planners from hospitals.

October 18th is a listening session in Charlotte where beneficiaries will provide feedback on what they need. We will want to know:

 Perceived barriers  What do they need?  Tell us what is working  Is it possible to compare duals discharged with no readmits to those discharged with readmits?

Data and resources that can be useful:

 Services included in the Medicaid waiver programs  Network will share the compiled results of the CRC Focus groups in Forsyth  QIO may be helpful

Group agrees to meet every 2 weeks at 1 p.m. on the following dates. A call in number will also be provided.

SUBSEQUENT MEETING DATES:

 October 3rd  October 21st  November 7th.

The below notes are taken from notes put up in the walls during the meeting

Page 1 - “Questions (Qs) for Listening Session”  What are the barriers?  What has worked well?  Match people with same but different hospitals readmission rates and compare supporting their level of supports

Page(s) 2/3/4 - “Challenges”  Cost 4 | P a g e  Lack of Data – especially for those not in an institution  Two different 800 #s for Medicaid and Medicare  Lack of flexibility  Eliminations of portable x-rays  Mobile Crisis Teams  Lack of spending flexibility with non-medical supplies/needs  Limited Support for caregivers  No Pay for Personal Assistants (PA’s) - Medicaid- to go with client to the doctor’s  Medicare does not pay for PA’s hours  CAP waiting list (16 weeks)  Personal Assistant Services (PAS) limited to in-home  Low wages and no benefits for care workers  Misunderstanding of palliative care versus hospice  Patients who are institutionalized - lack of access to outside service providers  Transportation  Access to qualified speech language pathologists  Elimination of care-line  Waiting list for transportation and meal delivery programs  Section 8 and other public housing does not practice universal design  Limited number of weeks allowed for hospice at home

Page(s) 5/6/7 - “Solutions”  Nurse practitioners in nursing homes  Palliative care in nursing homes  Hospice care in nursing home improves the quality of care  Intervention and educations at senior centers, adult day care, and senior housing  Building flexibility  Hospital to home transition model  Provision of home safety alerts (free)  DMEs – being open minded and current with technology  Training people (professional staff) how to ask correct questions and how to answer appropriately  Tele-medicine, allow as billable service  Pay family members when providing care giving  Innovative programs such as” Hospital at home” in Maryland and “Cash and Care”  Consumer and Provider education

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